Echocardiogram, STEMI and Stent - Cardiovascular Update

See OMI vs. STEMI philosophy in action

Dr. Smith's ECG Blog

DECEMBER 22, 2022

He visited an outpatient clinic for it and an echocardiogram and exercise stress test was normal. In the meantime, cardiology consultant sees the patient and performs a bedside echocardiogram which revealed no major wall motion abnormalities. The lesion was successfully stented. He has 40 packs-year of smoking history.

STEMI

STEMI Chest Pain Myocardial Infarction Electrocardiogram

A man with chest pain off and on for two days, and "No STEMI" at triage.

Dr. Smith's ECG Blog

JUNE 19, 2023

This ECG was read as “No STEMI” with no prior available for comparison. It is true this ECG does not meet STEMI criteria (there is 1.0 The Queen of Hearts sees it of course: Still none of these three ECGs meet STEMI criteria. Two stents were placed with resultant TIMI 3 flow. What do you think? Of course not.

Chest Pain

Chest Pain STEMI Cardiogenic Shock Ischemia

What do you think the echocardiogram shows in this case?

Dr. Smith's ECG Blog

MAY 13, 2020

What do you think the echocardiogram shows? One would not expect wall motion to recover so quickly after stenting, so this is good evidence that the POCUS echo was indeed accurate. Cath lab activated Dual antiplatelet therapy and heparin given. NTG drip started. Pain better still. First trop I returns at 1.5. Is this OMI?

Echocardiogram

Echocardiogram Ischemia Chest Pain Blog

Cath Lab occupied. Which patient should go now (or does only one need it? Or neither?)

Dr. Smith's ECG Blog

OCTOBER 15, 2024

A prehospital “STEMI” activation was called on a 75 year old male ( Patient 1 ) with a history of hyperlipidemia and LAD and Cx OMI with stent placement. Additionally, a bedside echocardiogram showed no wall motion abnormality and normal LV function. It was stented. He wrote most of it and I (Smith) edited.

Chest Pain

Chest Pain STEMI Echocardiogram Stents

Pulmonary Edema, Hypertension, and ST Elevation 2 Days After Stenting for Inferior STEMI

Dr. Smith's ECG Blog

APRIL 12, 2013

A male in his 40's who had been discharged 6 hours prior after stenting of an inferoposterior STEMI had sudden severe SOB at home 2 hours prior to calling 911. Is this acute STEMI? Is this an acute STEMI? -- Unlikely! He had no chest pain. Medications were aspirin, clopidogrel, metoprolol, and simvastatin.

STEMI

STEMI Pulmonary Stent Stents

"Non-STEMI" is a worthless term.

Dr. Smith's ECG Blog

OCTOBER 30, 2023

A 60 yo with 2 previous inferior (RCA) STEMIs, stented, called 911 for one hour of chest pain. Here is his most recent previous ECG: This was recorded after intervention for inferior STEMI (with massive ST Elevation, see below), and shows inferior Q-waves with T-wave inversion typical of completed inferior OMI.

STEMI

STEMI Heart Failure Stents Stent

Occlusion myocardial infarction is a clinical diagnosis

Dr. Smith's ECG Blog

DECEMBER 11, 2023

Recall from this post referencing this study that "reciprocal STD in aVL is highly sensitive for inferior OMI (far better than STEMI criteria) and excludes pericarditis, but is not specific for OMI." Here is the angiogram after stent placement. Her contrast enhanced echocardiogram is shown below in the parasternal short axis view.

Myocardial Infarction

Myocardial Infarction Chest Pain STEMI Blood Pressure

The Computer and Overreading Cardiologist call this completely normal. Is it?

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

EKG initially negative but repeat shows a few T wave abnormalities… There is a chance this could be non-cardiac pain” At 1518, an echocardiogram showed normal LV size and systolic function with hypokinesis of the mid and distal anterior wall and the mid and distal septum. At 1605, another repeat troponin resulted at 5.271 ng/mL.

Chest Pain

Chest Pain Blog Hospital Tachycardia

Precordial ST depression. What is the diagnosis?

Dr. Smith's ECG Blog

JANUARY 1, 2013

Precordial ST depression may be subendocardial ischemia or posterior STEMI. If you thought it might be a posterior STEMI, then you might have ordered a posterior ECG [change leads V4-V6 around to the back (V7-V9)]. So there was 3-vessel disease, but with an acute posterior STEMI. There is no ST elevation. See the list below.

STEMI

STEMI Ischemia Chest Pain Myocardial Infarction

Circumflex Occlusion May be Subtle or Invisible on the ECG

Dr. Smith's ECG Blog

MARCH 2, 2009

reports MI in 2001 with a stent placed in the "marginal" artery. A stat echocardiogram would have helped to make this diagnosis and facilitate timely reperfusion. First, this patient had a known stent in the "marginal" artery and thought he was having a heart attack. Pain is similar, but associated with less SOB.

Heart Attack

Heart Attack Heart attacks STEMI Echocardiogram

QS-wave in V2: 2 cases, different paradigms lead to different treatment times (STEMI - NSTEMI vs. OMI - NOMI)

Dr. Smith's ECG Blog

JANUARY 28, 2023

Only very slight STE which does not meet STEMI criteria at this time. I am immediately worried that this OMI will not be understood, for many reasons including lack of sufficient STE for STEMI criteria, as well as the common misunderstanding of "no reciprocal findings" which is very common with this particular pattern.

STEMI

STEMI Chest Pain Stents Stent

Chest pain in a 30-something: Is it Normal variant STE or OMI? Get the prior ECG, and don't trust Point of Care troponin assays!

Dr. Smith's ECG Blog

OCTOBER 2, 2021

He was successfully treated with one drug eluting stent. He underwent formal echocardiogram several days later, which confirmed the findings of anterior, and apical wall motion abnormalities. Practice putting the probe on the chest of someone with an obvious STEMI(+) OMI in order to look for regional wall motion abnormalities.

Chest Pain

Chest Pain Ultrasound STEMI Myocardial Infarction

Echocardiography, even (or especially) with Speckle Tracking, can get you in trouble. The ECG told the story.

Dr. Smith's ECG Blog

MARCH 28, 2017

EMS recorded these ECGs: Time 0: In V2-V4, there is ST elevation that does not meet STEMI "criteria," of 1.5 She was having a transient STEMI, briefly. It did not progress to full STEMI with loss of the anterior wall, as in this case. It was stented. She called 911. mm at the J-point, relative to the PQ junction.

STEMI

STEMI Risk Factors Bicuspid/Mitral Ultrasound

Concerning EKG with a Non-obstructive angiogram. What happened?

Dr. Smith's ECG Blog

DECEMBER 19, 2023

Unfortunately, we do not have those images for review, but the operators described a ruptured LAD plaque and they stented this area, which ensures the stability of the plaque. His echocardiogram showed normal wall motion. The patient did well afterward without any recurrence of symptoms. Before and after of the LAD shown below.

Plaque

Plaque Angina Blog Stents

This ECG was interpreted as completely NORMAL by the computer: What about it is THE critical finding??

Dr. Smith's ECG Blog

FEBRUARY 4, 2022

They were stented. Formal Echocardiogram: The estimated left ventricular ejection fraction is 58 %. These include about 60 occlusion MI (OMI) with clear ST segment elevation (none of which would be called “Normal” by the computer) and about 165 Non-STEMI. The peak troponin was 1863 ng/L. Why not very very high?

Chest Pain

Chest Pain STEMI Article Myocardial Infarction

First ED ECG is Wellens' (pain free). What do you think the prehospital ECG showed (with pain)?

Dr. Smith's ECG Blog

MARCH 9, 2013

Here is the prehospital ECG, with pain: Hyperacute anterolateral STEMI The medics had activated the cath lab and the patient went for angiogram and had a 95% stenotic LAD with TIMI-3 flow. A stent was placed. For those who depend on echocardiogram to confirm the ECG findings of ischemia, this should be sobering.

Myocardial Infarction

Myocardial Infarction Chest Pain Ischemia Angina

Opiate overdose, without chest pain or shortness of breath. Cognitive dissonance.

Dr. Smith's ECG Blog

NOVEMBER 1, 2022

The 50-something patient with history of coronary stenting and slightly reduced LV ejection fraction. In the setting of prior stenting and reduced left ventricular ejection fraction, would pursue a heart team revascularization approach Syntax score 28.5, This alone could be due to LVH, but V4 could NOT be due to LVH.

Chest Pain

Chest Pain Coronary Artery Bypass Graft Pericarditis Blog

What if your system adopted the recommendation that a computer "normal" ECG need not be shown to the doctor?

Dr. Smith's ECG Blog

JUNE 11, 2024

Now it is a full blown STEMI of 3 myocardial territories: inferior, posterior, and lateral But at least it does not call it "Normal." Successful drug-eluting stent placement opening up 95% mid RCA stenosis to 0% residual Nonobstructive left system disease. Formal echocardiogram: Systolic function is at the lower limits of normal.

Chest Pain

Chest Pain STEMI Exercise Blog

A man in his 70s with chest pain during a bike ride

Dr. Smith's ECG Blog

SEPTEMBER 30, 2019

Slow TIMI 2 initially with brisk flow status post percutaneous coronary intervention with 18mm drug-eluting stent. Unfortunately there is no echocardiogram accessible because the patient checked himself out of the hospital in order to get back to his home state before it could be completed. To our knowledge, the patient did well.

Chest Pain

Chest Pain Pulmonary ACE Inhibitor Pacemaker

Infection and DKA, then sudden dyspnea while in the ED

Dr. Smith's ECG Blog

NOVEMBER 22, 2023

See this post: What do you think the echocardiogram shows in this case? 20% of cases that everyone would call a STEMI have a competely open artery by the time of angiogram 60-90 minutes later. Important point: when there is diffuse subendocardial ischemia but no OMI, a wall motion abnormality will not necessarily be present.

Ischemia

Ischemia Chest Pain Echocardiogram Myocardial Infarction

An athletic 30-something woman with acute substernal chest pressure

Dr. Smith's ECG Blog

JULY 31, 2018

It is equivalent to a transient STEMI. Not much, but studies of STEMI and NonSTEMI show that about 70% of those diagnosed with STEMI have a peak troponin I above 10 ng/mL and that about 70% of those diagnosed with NonSTEMI have a peak troponin I below 10 ng/mL. The lesion was stented. Again, cath lab was not activated.

SCAD

SCAD Chest Pain Myocardial Infarction Ischemia

A dialysis patient with nonspecific symptoms and pseudonormalization of ST segments

Dr. Smith's ECG Blog

SEPTEMBER 29, 2018

I think a good start would be a posterior EKG and a high quality contrast echocardiogram read by an expert. It was thought to be an in stent restenosis and thrombosis from a DES placed in the same region 6 months prior. His prior EF from an ECHO 6 months prior indicated 35% LVEF. What would you do in this scenario?

Chest Pain

Chest Pain Myocardial Infarction Cardiac Arrest Ischemia

Three prehospital ECGs in patients with chest pain

Dr. Smith's ECG Blog

AUGUST 6, 2024

Elevated troponins prompted an echocardiogram — which revealed an apical wall motion abnormality (WMA). It definitely does not fulfill STEMI criteria, and I would argue that it would not lead to cath lab activation in most centers. Patient #1 in today's post did not get expert ECG interpretation. The ECG shows ST depression in lead V3.

Chest Pain

Chest Pain Ischemia Pericarditis Tachycardia

A young patient with diminishing pain with a subtle but diagnostic ECG.

Dr. Smith's ECG Blog

DECEMBER 18, 2022

Compare to the anatomy after stenting: The lower of the 2 now easily seen branches is the circumflex, now with excellent flow. Next day echocardiogram showed inferolateral hypokinesia with an EF of %45-50. This is seen just millimeters beyond the tip of the catheter. The patient recovered well. His peak troponin was over 5000 ng/L.

Myocardial Infarction

Myocardial Infarction Chest Pain Blog Echocardiogram

See OMI vs. STEMI philosophy in action

A man with chest pain off and on for two days, and "No STEMI" at triage.

What do you think the echocardiogram shows in this case?

Cath Lab occupied. Which patient should go now (or does only one need it? Or neither?)

Pulmonary Edema, Hypertension, and ST Elevation 2 Days After Stenting for Inferior STEMI

"Non-STEMI" is a worthless term.

Occlusion myocardial infarction is a clinical diagnosis

The Computer and Overreading Cardiologist call this completely normal. Is it?

Precordial ST depression. What is the diagnosis?

Circumflex Occlusion May be Subtle or Invisible on the ECG

QS-wave in V2: 2 cases, different paradigms lead to different treatment times (STEMI - NSTEMI vs. OMI - NOMI)

Chest pain in a 30-something: Is it Normal variant STE or OMI? Get the prior ECG, and don't trust Point of Care troponin assays!

Echocardiography, even (or especially) with Speckle Tracking, can get you in trouble. The ECG told the story.

Concerning EKG with a Non-obstructive angiogram. What happened?

This ECG was interpreted as completely NORMAL by the computer: What about it is THE critical finding??

First ED ECG is Wellens' (pain free). What do you think the prehospital ECG showed (with pain)?

Opiate overdose, without chest pain or shortness of breath. Cognitive dissonance.

What if your system adopted the recommendation that a computer "normal" ECG need not be shown to the doctor?

A man in his 70s with chest pain during a bike ride

Infection and DKA, then sudden dyspnea while in the ED

An athletic 30-something woman with acute substernal chest pressure

A dialysis patient with nonspecific symptoms and pseudonormalization of ST segments

Three prehospital ECGs in patients with chest pain

A young patient with diminishing pain with a subtle but diagnostic ECG.

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